Narcotics and OD’s
Uppsala University, Sweden, November 25th 2015 1 PM - 4.30 PM
Arranged by U-FOLD / Uppsala University
Nordic seminar for 75 researchers, experts and decision makers debating on the issue of
increasing deaths rates due to drugs across the Nordic countries being amongst the
highest in Europe according to the EU drug agency EMCDDA and a shared governmental
focus to reduce such overdose (OD) deaths. The Swedish National Board of Health and
Welfare are currently preparing for February 2016 a strategy report on reducing OD deaths
to the Swedish government. A joint Nordic scientific medical initiative in misuse treatment
research is under formation to coordinate and improve quality research of misuse
treatment and reduce morbidity and mortality of this disease.
Introduction: Professor Fred Nyberg, Coordinator of U-FOLD, Uppsala University
Misuse of drugs is a chronic relapsing medical disease. The disease has very high
consequences for the individual and for society. There is a need for coordinated medical
initiatives across the Nordics to counter morbidity and mortality of this disease. Thanks to
the experts of this symposium to offer their knowledge and experience on several
naloxone pilots to the work of the Swedish investigation.
Drug related deaths in Finland: Professor Hannu Alho, Helsinki University
EMCDDA places the Nordic countries with the highest OD deaths rates in Europe. The
definition of OD and forensic traditions varies amongst countries and even within countries
which jeopardizes the quality of data. Within the Nordic countries from 1991-2012
methadone is gradually replacing heroin as causative agent and for Finland in particular
buprenorphine is present in serum of the diseased. Finland and Sweden sees a gradual
increase of OD incidence over time.
Deaths, OD and naloxone spray in Denmark: Chief consultant Henrik Thiesen,
Copenhagen.
Over the past 3 year’s naloxone a nasal spray (Prenoxad based (1mg) w rescue needle
and with Mucosal Atomisation Device) project, RED LIV, in the major cities in Denmark
has been concluded. 580 persons have been trained and 42 OD’s reversed. The positive
experiences are now supporting an easy-to-use and broader application for national
implementation which has been approved by the Danish government for 2016.
OD and drug-related deaths in Norway: Professor Thomas Clausen, Oslo University
Overdoses rates in Norway have been on a decline since its peak in 2001. This is a trend
that is contrasting Sweden and Finland, as well as many other EU-countries. Although
overdose rates are declining in Norway, we have had among Europe’s highest mortality
rates from overdoses, and as a response to this ongoing public health crisis the Norwegian
Government launched a national overdose prevention campaign in 2014. The overdose
prevention campaign included multiple strategies to reduce overdoses, and this is
important as opioid using populations at risk are diverse in characteristics. The strategy
includes the distribution of nasal naloxone to drug users and their peers as one of the
intervention, in addition to the switch campaign which promotes injecting drug users to
switch to inhaling instead of injection. Finally the Norwegian overdose prevention strategy
includes a 0-vision for overdoses inspired by the preventive work performed to reduce fatal
road traffic accidents and points to an ongoing potential to improve preventive efforts. The
nasal naloxone distribution is organized as a pilot project in Oslo/Bergen with naloxone
nasal spray distribution (Prenoxad based (1mg/ml) without rescue needle but with Mucosal
Atomisation Device). More than 1500 kits are distributed and more than 200 kits used in
OD situations (refills). Strategic aim is to distribute kits to a minimum level of 100/100.000
citizens in the pilot cities (this is 900 kits for the 2 cities in total), and this aim was achieved
within one year of the pilot project. A remaining challenge is to build infrastructure and to
have an effective and approved nasal device to get a sufficient effect on OD reduction on a
national level after the pilot period ends; that is in in 2017. Distribution in sufficient
numbers to obtain “Universal access” must be developed and negotiated with local
authorities following the experiences from the pilot cities. It is important that this kind of
intervention targeted towards drug users and their peers, is an acceptable intervention that
gets a good reception and reputation within the drug using population, in order for it to
have any effect.
Sweden has the highest OD rate in Europe – are the simple explanations? Chief
consultant in the police, Lars-Håkan Nilsson.
The absolute numbers of drug-related deaths and incidences was discussed in the context
of serum-findings in forensic samples obtained with a variation across Sweden. There is a
need for a uniform method of sampling and analysing Swedish OD data and to relate such
strategies to shared Nordic and even European standards to get the real tool to work from.
Panel discussion: Knowledge, possibilities and future
Berne Stålenkrantz (Swedish drug users union) and Leif Grönbladh (project leader,
Uppsala misuse clinic) joined the speakers at the panel:
Recent news from FDA informs that the Adapt Pharma (4mg) nasal device is approved,
and will become available in the US during 2016. It is unknown if and when this device will
become available in the Nordics – and it remains a question if this “high dose” device is a
good choice to use and if it will be acceptable to drug users? It may be that a very high
dose spray,as this one will result in more frequent unpleasant withdrawal effects when
applied, and that this could prevent its acceptability among drug users. This issue still
needs to be investigated, before a highly potent spray is to be distributed. Ideally a spray
with multiple doses with lower concentration of Naloxone to allow titration to desired effect
(restoration of respiration, but without acute withdrawal), would be made available.
In the absence of alternatives: maybe the new Adapt device will be acceptable? However
the panel warned that the high dose could cause unwanted reactions also involving heart
attacks, seizures - particular in Methadone intoxicated patients – and severe violence and
anger when using the Adapt device because of the high dose of naloxone precipitating
withdrawal through a rapid reversal. This might jeopardise the acceptance of take home
naloxone amongst drug users and citizens in general with severe negative effects on
programme acceptance in the longer term. The panel agreed on that the unfavourable
benefit/risk assessment of such high dose and strongly recommended a titration strategy
of multiple lower doses in order to assist breathing before the ambulance arrived.
Scope of national implementation of future naloxone nasal device strategies?
To reach the full reduction of OD the most important parameter is to ensure full access for
the misusers to quality MAT with low threshold. Supplementary to this a “Universal access”
strategy on easy-to-use naloxone nasal devices must be agreed with authorities so
“everyone” can get hold of such device without limitations. The panel agreed on such
strategy would be the most efficient to reach the goal of significantly reducing OD deaths.
Overall a combination of high quality treatment and easy treatment access, also harmreduction strategies needs to be in place.
OMT treatment in prisons, naloxone distribution upon release are also important strategies
to be implemented in a community aiming at significant reductions in overdose deaths.
End of symposium